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One-year review of COVID-19 in the Arab world Nasar Alwahaibi ( nasar@squ.edu.om ) Sultan Qaboos University Muna Al Maskari Sultan Qaboos University Buthaina Al Dhahli Sultan Qaboos University Halima Al Issaei Sultan Qaboos University Samiya Al-Jaaidi Sultan Qaboos University Shadia Al Bahlani Sultan Qaboos University Research Article Keywords: Arab world, Coronavirus, COVID-19, SARS-CoV-2 Posted Date: April 8th, 2021 DOI: https://doi.org/10.21203/rs.3.rs-400603/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Version of Record: A version of this preprint was published at Qatar Medical Journal on November 23rd, 2021. See the published version at https://doi.org/10.5339/qmj.2021.66.
One-year review of COVID-19 in the Arab world
Abstract
Aim: Coronavirus disease 2019 (COVID-19) has infected almost every country worldwide,
including all 22 Arab countries. We have been following the COVID-19 pandemic in all Arab
countries since it started. In this review, we aimed to assess the prevalence of COVID-19 in the
Arab world for twelve months and to compare these findings with other most affected countries.
Methods: World Health Organization, Worldometer and Ministries of Health websites were
used to search for COVID-19 data in all Arab countries. The period was from February 2020 to
February 2021. The data was analyzed using the Statistical Package for the Social Sciences
(SPSS) software version 23. Results: The median age in all Arab countries was 26.25. As of
March 01, 2021, the total confirmed cases of COVID-19 in all Arab countries were 4,259,756.
Iraq, Morocco, Jordan, United Arab Emirates and Saudi Arabia (SA) have the highest reported
cases with, 695,489, 483,766, 391,090, 390,453 and 377,383, respectively. The total number of
deaths were 72,950 cases and were dominant in Iraq, followed by Egypt, Morocco, Tunisia and
SA with 13,406, 10736, 8637, 8022 and 6494, respectively. In comparison with the topmost
affected countries, the data obtained from COVID-19 confirmed cases showed that Arab
countries are ranked fourth after USA, India, and Brazil. In terms of total deaths per million,
Arab countries come in the second last, before India, with only 165 cases. Conclusion: The
number of confirmed and death cases among all Arab countries trigger vital worries about
morbidity and mortality of COVID-19, respectively. However, younger population in the Arab
world may contribute to the less death cases of COVID-19 in comparison with the topmost
affected countries.
Key words: Arab world, Coronavirus, COVID-19, SARS-CoV-2.
1Introduction
The coronavirus disease 2019 (COVID-19) is a highly transmittable viral infection. By March
01, 2021, it has infected 114,687,163 and caused 2,543,285 deaths around the globe [1]. COVID-
19 is caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) [2], a positive-
sense, single-stranded RNA virus belonging to the genus Betacoronavirus [3]. Betacoronavirus
also includes severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East
respiratory syndrome coronavirus (MERS-CoV), both of which have caused SARS and MERS in
2003 and 2012, respectively [4]. Although SARS-CoV-2 shares about 79% of its genome
sequencing with SARS-CoV, however, it is much more infectious [5].
The clinical hallmarks of COVID-19 include fever, dry cough, sore throat, headache, fatigue and
breathlessness. In some cases, COVID-19 patients also showed that the disease could progress to
pneumonia, hypoxemia, acute respiratory distress syndrome, septic shock, blood clotting
dysfunction, multiple organ failure and finally death [6]. Coughing and sneezing are the main
spread mode of SARS-CoV-2 between humans. Several studies reported that close contact with
COVID-19 patients are at high risk of infection [7,8]. Although almost everyone is vulnerable to
this virus, elderly people and those with hypertension, diabetes, respiratory system disease,
cardiovascular disease and cancers are more susceptible to COVID-19 [9,10], however, the
prevalence of COVID-19 in children is less [11,12]. Several studies reported that men are more
prone to infection and death of COVID-19 than women [13,14,15].
2The recent introduction of the COVID-19 vaccines such as Pfizer-BioNTech, Moderna, Oxford-
AstraZeneca, Johnson & Johnson, Gamaleya, CanSino, and Sinopharm is hoping to reduce the
incidence of cases and protect more people. However, the insufficient production and late
arrivals of the COVID-19 vaccination as well as unwillingness for many people to be vaccinated
are another concern in many countries. Those who are hesitant to receive COVID-19 vaccination
are afraid about the vaccine safety [16,17]. For this reason, many countries worldwide have
launched COVID-19 vaccination campaigns.
Arab world contains 22 countries distributed as 12 in Asia and 10 in Africa. The Arab league
was formed to unite the Arab countries politically and to represent the interests of the people.
However, gender, race, socio-economic classes, layout and health care systems differ from one
Arab country to another. Previously, we published the COVID-19 data in all Arab countries for a
duration of five months and concluded that most Arab countries took some serious early steps to
minimize the outbreak of COVID-19 [18]. In this review, we aimed to assess further the
prevalence of COVID-19 in the Arab world from February 2020 to February 2021 and to
compare these findings with other most affected countries.
3Methodology
We used World Health Organization (WHO), Worldometer and Ministries of Health websites to
search for COVID-19 data in Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait,
Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia (SA), Somalia,
Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen. The period was from February
2020 to February 2021. Inclusion criteria include official information in clinically diagnosed
COVID-19 in English or Arabic. Exclusion criteria include unofficial information regarding
COVID-19 in all Arab countries, language restrictions to English or Arabic only and unspecified
date and location of the information or suspicion of duplicate information. The following
information was collected from each Arab country: total population, median age, date and
number of the first announced cases, number of monthly confirmed, death and cured cases,
preventive methods, and total testing methods used. The data was analyzed using the Statistical
Package for the Social Sciences (SPSS) software version 23 (SPSS Inc., Chicago, IL, USA).
Results are presented as numbers, percentages and means.
4Results
The total Arab population who live in Arab countries is 441,622,903. The first Arab country to
officially report the presence of COVID-19 was UAE with five cases on January 29, 2020. Egypt
was the second Arab country and the first Arab-African country to declare the presence of
COVID-19 on February 14, 2020. Comoros was the last of the Arab countries to declare the
presence of COVID-19 on April 30, 2020. Palestine reported the highest number of the first
announcement of COVID-19 with seven cases. The highest median age was in UAE with 38.4
whereas the lowest one was in Sudan with 18.3. Egypt recorded the highest population with
103,604,518 whereas Comoros showed only 881,774 people. All Arab countries utilized real-
time polymerase chain reaction (RT-PCR) as the testing method for SARS-CoV-2. UAE
performed the highest number of RT-PCR with 30,665,851 tests, followed by SA and Iraq with
13,633,077 and 6,846,243 tests, respectively. Yemen performed the lowest number of RT-PCR
with only 17,404 tests (Table 1).
As of March 01, 2021, the total number of COVID-19 cases in all Arab countries was 4,259,756.
In terms of total confirmed cases with COVID-19, Iraq, Morocco, Jordan, UAE and SA recorded
the highest reported cases with, 695,489, 483,766, 391,090, 390,453 and 377,383 respectively.
Based on the evaluation of 12 months from February 2020 to February 2021, the trend showed
that the month of November had the highest number of confirmed COVID-19 cases in all Arab
countries with 631,692 cases. In the same month, Jordan, Morocco, Iraq, Lebanon, and Tunisia,
scored the highest confirmed cases (Table 2).
5The total number of deaths in all Arab countries were 72,950 cases. Total number of deaths in
the studied period was dominant in Iraq, followed by Egypt, Morocco, Tunisia and SA with
13,406, 10736, 8637, 8022 and 6494, respectively. The trend demonstrated that November had
the highest number of deaths in all Arab countries with 10,797 cases. In the same month,
Morocco, Tunisia, Jordan and Iraq had the highest death cases (Table 3).
The total number of cured cases in all Arab countries was 3,744,127. Iraq, Morocco, UAE, SA,
and Jordan showed the highest number of cured cases with 635,931, 469,345, 381,221, 367,033,
and 348,599, respectively. The trend showed that November had the highest number of cured
cases in all Arab countries. In the same month, Jordan, Morocco, Iraq, Tunisia, and Lebanon
scored the highest cured cases (Table 4).
The epidemiological data presented in Table 5 analyses the Arab world in comparison to the
topmost 15 affected countries with COVID-19. This revealed that Arab countries are ranked
fourth after the USA, India, and Brazil based on confirmed cases of COVID-19. The data on
total deaths per million showed that Arab countries ranked second last before India, with only
165 cases. In terms of the total number of molecular tests for SARS-CoV-2, Arab countries are
ranked fifth after USA, India, Russia, and UK with 76,568,739 tests. Arab countries showed the
youngest median age with only 26.25 whereas Germany showed the oldest median age with
47.8. Other parameters, which include confirmed cases, cases per million, cured cases, tests per
million and population, are also compared in Table 5.
6Discussion
Despite that many Arab countries took early serious measures to control the infection of COVID-
19 such as suspension of flights and many events, closure of universities and schools, lockdown
of major cities, social distancing, quarantine and wearing of facial masks, COVID-19 is still
rapidly on the rise. However, due to the economic crisis, many Arab countries as with other
global countries lifted the restrictions prior to the satisfactorily reduction of confirmed and death
cases of COVID-19. Such an approach could lead to higher numbers of mortality and morbidity.
In the current study, we have been following the COVID-19 cases in all Arab countries since it
started. The number of confirmed cases has continued to increase gradually in most of the
studied countries and peaked in July 2020. The possible reason for that peak was that many
countries had reopened the shopping malls, private businesses and offices at full capacity [19]. In
August 2020, the trend of confirmed cases showed a decline in most of the Arab countries except
in Syria, Algeria, Libya, Oman, Tunisia, Morocco, Iraq and Lebanon. This is because many
countries reimposed extra restrictions and preventative measures to contain the peak such as
banning international flights, suspending Umrah and cancelling Hajj for the first time in SA
since 1932 [20-22].
Noticeably, Iraq has recorded the highest number of confirmed, death and cured cases. Despite
of air travel ban in Iraq, COVID-19 confirmed cases escalated because the returning Iraqi
citizens were exempted [23]. Iraq showed a dramatic increase in the confirmed cases starting
from July 2020. The possible explanations for that are lack of medical support and the relaxation
7of both curfews and movement restrictions by the authorities [24]. In addition, the partial reopen
of the border between Iraq and Iran for foodstuff trading has contributed to the increase of the
confirmed cases [25]. In December 2020, Europe reported a new variant of COVID-19 [25],
which could likely be one of the reasons for the increasing prevalence of confirmed cases in
many countries observed in January and February 2021.
Since the beginning of the COVID-19 crisis, the total death cases in the Arab countries was
highest in November, followed by a fluctuation between a slight decline and elevation. This
might be attributed to several factors such as: (i) the improvement of medical management and
the coordinated efforts of the health system, (ii) medical caregivers became more familiar in
dealing with the crisis and in alleviating patients’ suffering, (iii) the community awareness and
education of COVID-19 prompted immediate efforts in seeking of medical treatment to decrease
disease severity, (iv) the use of drugs such as Remdesivir, Tocilizumab, and Baricitinib increased
the quality of medical care [26-28], and (v) increased number of tests and testing methods
contributed to the reduction of the overall death rate as high numbers of tests enabled healthcare
providers to quickly detect and assess more cases with mild symptoms or even asymptomatic
cases. Apart from the medical care management system, governmental restriction strategies such
as closure of schools and businesses, bans on gatherings, quarantine for travelers, travel
restrictions, maintaining physical distance and including orders to stay at home limited viral
transmission and led to a drop in positive cases and, thus, a decrease in the deaths [29].
Although COVID-19 disease continues to be a big threat to the world, the numbers of cured
cases are considered extremely high. Usually, healthy individuals assumed by their strong
8immunity can tolerate the flu-like symptoms of this disease. Nevertheless, very few rare cases of
healthy young individuals have died from this pandemic without any clear evidence. Several
factors might affect how the human body’s immune defense system reacts to the virus. At the
individual level, the genetic makeup of the human body can play a key role in immune
responses. Lifestyle including healthy food and exercise play a major role in strengthening the
immunity. This speculation can be true in countries like Iraq, which showed 635,931 cured cases
as the top amongst the Arab countries (Table 4). Due to the unstable political conditions such as
Iraq, people are forced to engage in utilizing their natural resources to manufacture their own
local food and to work even harder to bring about positive changes. Another example is Morocco
and Jordan that scored the highest cured cases in which these countries share similar climate and
lifestyle that might influence the outcome of the disease.
Both the wealth of the country and the efficient health system have great influence on COVID-
19 cured cases such as UAE and SA that showed 381,221, and 367,033, respectively which are
among the top countries. Overall, the trend in the cured cases showed some fluctuations which
might be due to the above-mentioned factors that are either specific to some countries and not the
others.
We have previously conducted a study to compare between the Arab world and the topmost 15
affected countries with COVID-19. As of May 31, 2020, the COVID-19 total confirmed cases
for the Arab world showed 290,428 cases ranking it fourth amongst the top 15 countries [18].
Within a duration of 9 months, the total confirmed cases increased to 76,568,739 cases by March
01, 2021 representing an alarming situation despite maintaining the same rank (Table 5). The
9other 15 countries also showed an increasing trend of confirmed cases, however, Colombia,
Argentina and Poland superseded Peru, Chile and Canada climbing up to the top 15 affected
countries. While the Arab world may be ranked fourth in terms of the total confirmed cases, its
rank is second last before India in terms of cases per million population (9321) and deaths per
million population (165). These are very encouraging figures and indicate that the Arab world
after India has fewer cases as a percentage of its population as compared to the rest of the top
affected countries as shown in Table 5.
The other important parameter is the adequacy of testing. Increasing testing capacity is one of the
measures implemented to control the spread of COVID-19. The top 15 countries including the
Arab world showed increasing testing capacity in the number of tests per million conducted from
May 31, 2020 to March 01, 2021. Italy, Spain, and Germany were reported to scale up testing
and flatten the curve faster than other countries [30]. Despite these figures, there is still criticism
whether all the cases are being detected.
Several studies have considered that older age plays a vital role in influencing the severity of
COVID-19 disease and negative clinical outcomes than the younger population [31-33]. The
Arab world followed by India has the youngest median age and this could partly explain the
lower deaths per million population compared to the 13 top affected countries. Surprisingly,
Mexico also had a significant young median age of 29.3 compared to Germany (median age =
47.8) but recorded 1430 deaths per million whereas Germany had a much lower death per
million of 842.
10Our study is not an exemption of limitations. First, some potential risk factors, such as signs and
symptoms, gender, age, death causes, medications, duration of hospital admission and other
confounders (hypertension, diabetes, respiratory system disease and cardiovascular disease), that
can be associated with the confirmed, death and cured cases of COVID-19 were not available.
Second, many patients who were asymptomatic or had mild symptoms and who were treated at
home might not be included in these data. Thirdly, many non-Arab nationalities work in Arab
countries and most of the published data did not distinguish Arabs from non-Arabs. Finally,
while the data of tests per million are instructive of demonstrating increasing testing capacity, it
is not known whether some countries record the number of people tested or record the total
number of tests carried out as some people may require more numbers of tests to obtain accurate
results.
In conclusion, the number of confirmed and death cases among all Arab countries trigger vital
worries about morbidity and mortality of COVID-19, respectively. However, younger population
in the Arab world may contribute to the less death cases of COVID-19 in comparison with the
topmost affected countries.
Conflicts of interest
The authors declare no conflict of interest.
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